Dinah, ClinkShrink, & Roy produce Shrink Rap: a blog by Psychiatrists for Psychiatrists, interested bystanders are also welcome. A place to talk; no one has to listen.

Tuesday, September 18, 2007

This Post Is A Lie

Everything I'm about to say in this post never took place. I'm making it all up. I'm putting up this hypothetical story because it could happen someday, or maybe it already has happened but I just don't know it. Anyway, I'd like your thoughts.

Here's the story:

I'm sitting in my prison clinic and I hear inmates sitting out in the hall talking. One of the inmates happens to be my patient but he doesn't know I can hear him. He is bragging that the first time he met me he "told Dr. Clink all kinds of stuff" and got put on meds. He added that when he gets out of prison he will be "set" because he'll have "a check for life". He doesn't mind taking meds because the pills he gets are "good stuff that helps me rest" and that what he doesn't take he trades away.

Curious, I pull his chart and look up his intake history which I completed two months before. When I saw Inmate X then I noted that his hygiene seemed a bit poor but he was calm and polite. He was slow to answer questions and at times seemed distracted as though listening to internal stimuli. He was evasive about questions regarding his past psychiatric history and refused to elaborate upon prior symptoms or treatment beyond acknowledging one hospitalization in his late teens (he's now in his mid-20's). He didn't remember the name of the hospital and couldn't or wouldn't tell me why he was there. He was not suicidal. His speech was sparse, and although not overtly thought-disordered his questions at times were a bit 'off the mark' and tangential. He acknowledged feeling "paranoid" around other inmates but no clear delusions were elicted. The rest of his mental status examination was unremarkable.

Concerned about possible psychosis I start him on risperdal. At followup visits he reports medication compliance but gives no additional information other than that found in the intake history. No new or additional apparent symptoms are seen at followup.

So here are my questions, which I'm particularly interested in having our psychiatrist readers address: Does this patient truly have a psychotic disorder or have I misdiagnosed him? What would you do to differentiate psychosis from malingering? To differentiate malingering from "faking good" (or bragging) in an inmate with a real psychotic disorder? What do you do when the social worker comes to you to fill out entitlement papers on this inmate who has announced his intention to defraud social security?

2) I might wonder if this was a "cover" for feeling a bit awkward seeing a shrink.

3) If he said risperdal was helping him, I'd give him risperdal. After the comments on our last post, I'd be thrilled it wasn't hurting him. Not too many people who feel absolutely fine come searching for anti-psychotics.

4) It hasn't been my experience that 20-something year old prisoners with a history of a single hospitalization and vague symptoms get checks for life-- Disability is hard to get these days. I might tell the social worker what I'd heard, particularly if I'd confronted the patient. Or I'd fill out the form with a diagnosis of Psychotic Disorder, NOS , note that the patient gave little history, reported having a single prior hospitalization at an unknown facility and had vague symptoms of paranoia and mild cognitive disorganization.

5) I would wonder if the risperdal worked--he sounds like he was more fluent and organized with his buddy than he had been earlier with you. You didn't give a time frame or say how his mental status changed by the second visit.

6) He does a pretty good job imitating someone with a psychotic disorder...one might think a malingerer would elaborate more on first rank symptoms .....

Roy: I hint that he may be hallucinating but hiding it. Functional impairment may be his poor hygiene. Vague and nonspecific symptoms may be someone trying to hide his illness. You can't call his mother because you don't have a phone.

Anonymous: Exactly, I'd confront him about it at next visit. In prison, people without illness do come seeking antipsychotics for many reasons. For street value, as a sedative, and out of the belief it will give them a 'check for life'. I didn't give a time frame or treatment response history because the scenario was getting too long, but yes that's relevant. And yes he did a great job if he was malingering; most malingerers don't leave me wondering about their diagnosis. I can't call his mother because I don't have a phone.

Uh, with such an unremarkable history (and who wouldn't feel paranoid in prison; that is not psychotic, that is adaptive.) Bet ya the prior hospitalization was related in some way to drug abuse.I can't see a reason to prescribe for possible psychosis for a patient whose anwers are vague and tangential. That describes a whole heck of a lot of people ,like the many teens I know and guess what? 25 is the new 15. If, as a rule the state does not incarcerate people who may possibly, one day commit a crime why would a doc prescribe for someone with no florid syptoms? Why are you even asking when you already know all this?

P.S. Don't call his mother.The guy is 25. get him to sign a form so you can get his prior medical records.

>enter windowPrison Shrink's OfficeYou are in the office of a prison psychiatrist. A table seems to have been used recently for the preparation of food. A passage leads to the west and a dark staircase can be seen leading upward. A dark chimney leads down and to the east is a small window which is open.On the table is an elongated brown sack, smelling of hot peppers.A bottle is sitting on the table.The glass bottle contains: A quantity of water

>open sackOpening the brown sack reveals a lunch, a glove of garlic, and a cell phone.

>call motherWhat do you want to call mother with?

>call mother with cell phoneYou dial the mother's phone number and find that the number is disconnected.

I wish to identify myself as the first Anon who would continue risperdal, call the mother (hospitals rarely send me records and never send me useful ones and mothers are pretty good except when I don't have a phone), and fill out the form.

If we were only willing to offer medications to people who are able to articulate their mental phenomena, a lot of people would go untreated.

I wouldn't call his mother if he didn't want me to. Or if I didn't have a phone.

Whoa, Dinah. If we were only willing to offer medications to people who are able to articulate their mental phenomena, a lot of people would go untreated.

I find that concerning in light of the vague symptoms. Isn't this the same line of reasoning exposed in Rosenhan's experiment, where 8 people without mental illness told psychiatrists of a voice that said "thud" and all were diagnosed and treated?

It's not at all clear to me that the fictitious patient was malingering.

Lots of psychotic people don't feel psychotic, even if they do appreciate the help of an interested doctor who helps them sleep.

Explaining - to oneself or to others - that your psych meds are just to help you sleep, or to help you sleep and serve as currency, may be the one that feels right and makes most intuitive sense. Even for someone who is clearly floridly psychotic. In the latter case you wouldn't be concerned if you heard him saying that he snowed you for meds: the diagnosis was clear to you. The statement you heard him make would go to lack of insight or faking good. The reason you think that it goes to malingering is that you weren't convinced of your original diagnosis in the first place.

I would tend to go with the original diagnosis anyway:1) If I were trying to score an antipsychotic I would go further than not talking much. I'd probably say yes to at least one of your questions about hallucinations or delusions. (And if I didn't talk much, that doesn't match the later statement that I told you 'all kinds of stuff.')

2) Needing a sleep aid is probably completely legitimate in prison. If the only way to get some sleep - essential for physical and mental health - is to snow a doctor, then whatever, fine. (Unless of course you are the snowed doctor in question.) When in doubt, can you go with the possiblity that someone isn't actually psychotic, just hasn't slept properly since weeks before incarceration? And that drugs that help them sleep - even if they are antipsychotics - are possibly no worse than the alternative of not sleeping?

3) On the subject of the harm to society of making us pay for disability for people who are not psychotic. That's a tough one, and it's not for individuals to decide. But can that be balanced against the harm to society of making us pay for the incarceration of people who are not really all there and are likely limited in their ability to earn an honest steady living? That is, that someone on disability might be less likely to end up in jail a year from now? No, I don't mean make false statements on entitlement papers. I mean be as accurate as you can, but maybe you don't need to lose much sleep over the fact that you might not be able to be that accurate.

Of course what I would tend to do is complete nonsense because I am not a doctor and know nothing of prison or prisoners. Your answer to these questions is going to be nuanced and educated, which is why I'm so interested.

Thanks, Clink. This is a nice exercise. (I keep popping over here tonight while I work on modding the Healthcare Blogger Code of Ethics forum, which I managed to screw up the SQL tables, but then have --somehow magically-- managed to repair, without really knowing what I am doing.)

You know, there are more options than just:-psychosis-malingering

He could be just low functioning (eg, 5th grade education, borderline intellectual functioning, organic personality disorder from head trauma when he was 18 and requiring hospitalization, etc). That could explain reduced hygiene (as could adaptive response to incarceration --strategy to appear nondescript, etc)-- and mild disorganization.

I still think the most important missing info is -- tell 'em Enrico -- the HISTORY. History is so critical. In C-L psychiatry, obtaining history is my most useful tool in figuring out why someone is not "acting right". Usually more helpful than a CT, MRI, EEG, RPR, TSH, B12, or any of the other things we may request. Given the risks of atypicals, I'm not yet convinced that the risk of no treatment is greater than the risk of treatment. It is hard to treat a bunch of maybe's and might's.

Alright, I'll shut up now. Feeling a bit contrary tonite.

>close laptopThe computer makes a brief whirring sound and then becomes quiet. A soft, slowly pulsing white light is seen on the edge of the computer.

>upYou ascend the dark stairway and see a door to the north.

>nOpening the door reveals an unmade bed. You suddenly feel very tired and find yourself lying down and closing your eyes, drifting to sleep as you dream about the Leather Goddesses of Phobos.

Roy: Get some sleep. Nice MMORG though. BTW, if you find a cell phone in a lunch bag in prison turn it in immediately to the duty lieutenant so they don't think it's your contraband. Outside history is not worth losing your job over.

Allison: I think I'd tend to go with my original diagnosis too, because this isn't your typical prison malingering case. The issue of treating insomnia, believe it or not, can cause knock-down drag-out fights among correctional psychiatrists. It's controversial. I fall into the 'I only treat brain diseases and you're not diseased' camp.

As far as the disability papers go, it depends on the symptoms the inmate is having at the time I get the papers. You'd be surprised how many times I'm asked to fill out disability papers on guys who are employed as cadre workers within the facility.

Does this patient truly have a psychotic disorder or have I misdiagnosed him?You've made a valid diagnostic formulation, a robust diagnosis will only become evident over time. Given the duration, you can't yet make an ICD-10 diagnosis of schizophrenia so would be classifying this presumably as F23.0 acute polymorphic psychotic disorder without symptoms of schizophrenia (or if the apathy and reduced prosocial behaviour and suboptimal functional level were compelling you could go for F23.1 acute polymorphic psychotic disorder with symptoms of schizophrenia).

What would you do to differentiate psychosis from malingering? Discreetly observe over time. It's hard to maintain a behavioural repetoire, sustained over time, consistent with psychosis when also distracted by inmates etc.

To differentiate malingering from "faking good" (or bragging) in an inmate with a real psychotic disorder?Evidence of psychopathology. Particularly evidence of thought disorder in dialogue generated freely, such as this overheard speech, which did not contain robust evidence of psychopathology you'd ascribe any significance to, i.e. we still have no evidence of formal thought disorder.

What do you do when the social worker comes to you to fill out entitlement papers on this inmate who has announced his intention to defraud social security?Comment on that fact, it's simply an objective statement that social security should be aware of.I'd also comment that - no long term or severe and enduring mental health diagnosis has been made.- if true, that functional level is sufficient to manage autonomously (and without supervision or support)- if still true, that he's still a capacitated adult and responsible for his own actions and choices, even negative life choicees- if true, that no functional assessment has been undertaken evidencing deficits that would preclude him working and as such he should be in a position to seek employment

Hygiene: "a bit poor"Demeanor: "Calm and polite." "as though listening to internal stimuli". That is an assumption about someone you do not yet know well enough.Evasive? The guy is in jail. Not suicidal. That is good.Not overtly thought-disoriented but questions are tangential. There could be so many reasons for this, but with no prior history (are you even certain about the prior hospitalization yet?) why not choose to focus on the fact that his thoughts are not disorganized.No delusions. That is good. Feeling paranoid around other inmates.He probably should be. Define paranoid though. Is he worried about what can realistically happen in prison? If so, seems normal.Otherwise unremakable. He seems altogether unremarkable.If you were to take all the people who fit the description that you gave and started them on Risperidal, the company could not make enough to keep up with demand. Tip: buy their stock.

Hi,What if you did misdiagnose him? Not treating a potential psychotic disorder is harmful to this young man (we know what effects psychosis have on brain substrate). Giving him an antipsychotic is potentially harmful, but at least you can observe for side effects as long as he is in your care. Time will tell - if he is truly ill, he will eventually end up in treatment again. If not, it's unlikely he will sustain the charade and go through the immense amount of paperwork and effort needed to sustain a credible disability claim "for life". I'm wondering if the bureaucracy actually weeds out long-term malingerers.

To differentiate malingering from psychosis - our psychologist colleagues have thought about this - do you have access to psychometric testing? A couple of links --http://www.leaonline.com/doi/abs/10.1207/s15327752jpa5203_18?cookieSet=1&journalCode=jpahttp://www.forensicpsychology.org/exports/malingering.htm

As for filling out disability papers, I would. This guy has a lot stacked against him already - mid 20's in jail, one prior hospitalization, current "soft" sx, if he's in for a felony he's going to be at a terrible disadvantage when he gets out. Again, half the people I see on disability in a community mental health center practice can't sustain their benefits without having gaps because of hospitalization or other bureaucratic issues.You trusted your experience and instinct, and prescribed Risperdal. So what? It doesnt seem likely that you would be way off the mark that often - think of this as a "number needed to treat" analysis, and chalk it up to epidemiologic variance (if you're wrong, that is).Love the blog, keep writing.

Flash to real life: I'm in Target on an emergency dog food run (out of wet food), the phone rings. It's Camel-- "I need ClinkShrink's phone number, my patient isn't getting meds in jail and no one ever called me." To which I said, "if you'd read the last blog post, you'd know the docs don't have phones in jail." "Well, give me her cell number."...and the song goes on....

I would give him an MMPI-2. If he's truly psychotic and not faking bad, you should be able to tell. Heck, I'd come out there and give him an MMPI for you, but I lack a license, a plane ticket to Maryland, and my own MMPI kit!

This reminds me of my friend the prison psychologist's strategy for weeding out the malingerers in the intake process. If they report any psychotic symptoms, she asks leading questions about floating red dots that speak Japanese. The malingerers (at least the unsophisticated ones) get all excited that she "knows" what they are going through.

Dinah: I took care of Camel and her patient. I think if your hair hurts when you pee you should stop keeping your toupee on the toilet seat.

Gerbil: No MMPI-2 or malingering tests available for me I'm afraid. Also, malingering doesn't exclude the possibility of a real underlying disease. And if his hairy tongue hurts when he pees...eyewww, let's not go there.

APSMD: Thanks for the nice summary. I'm also curious on what social security does to investigate and/or prosecute fraud.

Anonymous (the most recent one, I'm losing track): Responding to unseen stimuli is an observation, not an assumption. Evasiveness actually isn't an issue for most of my patients, even in prison, at least not to the extent presented in this hypothetical. My patients generally don't have any reluctance to tell me about their psych history and/or symptoms. When I see evasiveness about this it's generally somebody who doesn't want me to know how ill they were.

The suicide process, I mean, Social Security disability process, is far more than jumping through hopes and a billion checkpoints and weeding out fakers - I suspect a number of people have killed themselves because of it, as I know I came close several times myself.

Three. Damn. Years.

And for what?

The judge said, as I was wracked with sobs that I could not control as I realized all my hopes of being able to afford and get treatment had disappeared, that it is far better that the process sometimes excludes people who legitimately need the disability money, who are legitimately ill, etc., than to let a fews con-men/women through . . . .

I thought, you'd rather see me die than have the oh so horrible thought (sarcasm here) that a small percentage were faking their way through the system?

I've never posted much about my hearing, although I will, sometime.

But . . . when you have your fate, your HEALTH, you ability to EXIST, at least in much of a functional way, when you have your hopes and dreams of being able to beat this @#%$#$^%#^WE$^#^$ing stuff, and not have the constant fight that takes and buries so much of you . . . when they just cut off your HOPE . . . .

. . . there are no words.

When society would rather people who desperately need help to survive, get no help at all, and even die, just to keep some stupid fakers from getting through . . . when LIFE itself is not worth saving, by society, because HEAVEN FORBID someone underserving should get one cent.

3 Damn Years - a personal hell and ever deepening awareness of the functional, emotional, mental, social, physical, etc. difficulties I experience, a personal hell of ever stripping away more and more of the defenses I'd unconsciously constructed to keep from seeing/realizing how badly I'm existing/interacting/not interactiong and so much more . . . . a personal hell of coming face to face with the worst of a person's soul, dredged up over and over again, in greater and greater detail, for all the world to see, all the while feeling like a WHORE for spilling your soul out for display, for sale, for begging with everything you've got.

3damnyears.

74 dollars and some odd cents a month.

Yep, I pimped my heart, mind, and beingness out, all right, for alot less than 30 silver pieces.

Could you take him off the risperidone for a while and monitor his symptoms, or don't you do that where you are? Or try him on a different antipsychotic with a less pleasant side-effect profile and see if he still feels motivated to take it?

I'm not a psychiatrist, I'm a patient, (bipolar disorder) though I've done graduate-level work in pyschology, and have been told by psychologists other than my own that I have great insight into human behavior.

To your first question, I would say, "dunno, but it seems like you lept into a diagnosis on inadequate evidence."

To your second, I say that the only way to know he is psychotic is to let him go into paychosis.

My current shrink certainly feels that way: even though my previous shrinks had each seen me during or shortly after psychotic episodes, he refused to second their opinions until he saw one himself, then attempted to have me involuntarily commmitted, after the episode was over.

I bear him no ill will for this... though episodes are unpleasant when they are occurring, the human mind has a remarkable capacity for erasing past pains. I've had at least 7 episodes that I know of, and suffer little or no trauma for them.

I can tell you that the supposed brain damage from episodes is over-hyped. I still function extremely well when I'm not psychotic or severely depressed. My IQ was tested at 150 at age 22 and 142 at age 43. I seem not to have suffered any damage not expected simply from aging.

To the question of faking and/or bragging: Dont' really know about faking, but I can tell you that a 25-year-old talking to his peers will lie like a rug to make an impression. Discount everything he says to a peer.

And finally, the disability question.

Do you have any idea how difficult it is to win a disability claim on Psych grounds? For the entire time the claim is pending, the patient is only allowed $900/mo income. Slip once, and it is OVER.

And the doctor's evaluation really is important, but is not even close to being the only thing considered. You must have it, but it is nowhere near being a pass. Make just one remark about the possibility of malingering, and you will doom his case.

On top of all that, the benefit amount is limited by what you've paid into the system. Most people under 30 going onto disability receive in the neighborhood of $650 dollars a month (or less).

Limited to that income, he will likely re-offend and wind up back in prison.

On a side note: Why are doctors so unwilling to treat insomnia? My own experience is that sleep in large quantities will halt a psychotic episode or mania in it's tracks, and my first shrink treated me that way. Klonopin, Ambien, and an anti-depressant famed for knocking patients out for 8-10 hours (sorry, forgot it's name in the long list I've been prescribed over the years) did a marvelous job of staving of mania and psychosis. Just askin'

Hey...had to respond to this, because its so familiar. I have learnt to go by a few rules when not sure-1. Don't treat. What's your hurry? Watch the patient..the malingerer will declare him/herself sooner or later.2. Collateral, collateral, collateral. Talk to family. Get records. Ask the nurses to watch the patient.3. NEvEr fill out disability papers if you're not sure.

This is just what I believe. And I'm only a second year Psych resident.

One of the plethora of laughable if it wasn't so STUPID (on their part) and tragic things about the process is that, apparently, I answered their questions on that zillion question form I filled out when I went to their psychologist. And, in conjunction, that I am INTELLIGENT.

Apparently, intelligent people can't be disabled.

Also apparently, intelligent people don't work at that state agency.

Geez!!!! One of the first things the lawyer did at the hearing was counter this, with FRIGGING COMMON SENSE people. Geez!

When I was filling out those zillion questions, I did my best with the focus of, oh, gee, only the REST OF MY LIFE depends on my doing my honest best to answer the questions. Apparently, that was the wrong move (I am not giving legal or disability process advice here, and this msg. will self destruct in 5 seconds.)

Can you picture a room full of people, the room full of people that review the application at that part of the process (just post-their-psychologist), scoffing at my sincerity and thoroughness? Oh, I also happened to be manic that day, in a way that was kind of helpful, ie, I was able to just keep going and going and going and going and . . .well, you get the picture.

Yeah, I know this post wasn't about the disability process, but I guess, with the one year coming up of that hearing, stuff is just coming up I guess. I need to go make it come up on my blog, lol.

The hearing was the first I was hearing of their incredulity and ridicule of my thoroughness on those questions, whereas the experts in the room had already been through my file. I was quite shocked and dismayed, I can tell you, especially at the mocking tone of what that review board had said.

And they can and will totally dismiss doc's reports without even the wave of a hand, if they should just think, hey, I'm not going bother giving any weight to what this doc says at all; I'm not even going to bother to treat it as relevant.

If they hadn't done that, I'd be getting disability, and be on Medicare, and be able to get treatment. I HAD THE FRICKING DATE BEFORE THE DATE OF ELIGIBILITY CUTOFF that they needed, and they completely dismissed my gp because he's a gp, or because there was REPEATED, over quite a few years, documented times I saw him for depression, w/problems functioning and stuff.

You know, I do not think I was capable of making the decision to waive my right to an appeal, just so's I (but more importantly, I guess, the lawyer) could get paid; me, a pittance a month of SSI and give up any right to full disability, and the lawyer several thousands of dollars. I feel like I may have been misled as to my chances in this whole situation, and feel like the process may be incentivizing some lawyers to downplay the chances of an appeal, but I have no idea. What the hell was I supposed to say, anyway.

Oh, and I agree w/Neha - do not put a doubt in there if you have further chance to observe, diagnose, etc., because they will not only take any excuse to stamp "DENIED" on the app, they will make up the flimsiest and stupidest of excuses.